VA Form 21-22A Appointment of Individual as Claimant's Representative

What Is VA Form 21-22a?

VA Form 21-22a, Appointment of Individual as Claimant's Representative, is an official form used by the Department of Veteran Affairs (VA) in order to select a veteran's representative to claim VA benefits. This form will allow the VA to identify a representative and have their contact information on file.

21-22a Form may be confused with a VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative. VA Form 21-22 is used when a veteran wants a Service Organization to represent them and VA Form 21-22a allows to select an attorney to represent the claimant.

Form 21-22a is used by accredited attorneys, accredited agents, private individuals, or service organization representatives who assist claimants in the preparation, presentation, and prosecution of claims for VA benefits.

The form contains two pages with instructions in the fields. The individual named on this form should be copied on all correspondence issued by the VA regarding the claimant.

VA Form 21-22a fillable version is available for digital filing and download below.

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OMB Control No. 2900-0321
Respondent Burden: 5 Minutes
Expiration Date: 08/31/2018
1. VA FILE NO(S)
Include prefix)
(
APPOINTMENT OF INDIVIDUAL AS CLAIMANT'S REPRESENTATIVE
Note - If you would prefer to have a service organization assist you with your claim, you may use VA Form 21-22,
"Appointment of Veterans Service Organization As Claimant's Representative."
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA, published in the
Federal Register. Your obligation to respond is voluntary. However, failure to respond provide the requested information could impede the recognition of your representative and/or
identification of disclosable records. Except for information protected by 38 U.S.C. 7332, your representative is not prohibited from redisclosing records. The responses you submit are
considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to recognize the individuals appointed by claimants to act on their behalf in the preparation, presentation, and prosecution of claims for
VA benefits (38 U.S.C. 5902, 5903, and 5904) and for those individuals to accept appointment. We will also use the information to verify consent for disclosure of VA records to the appointed
representative (38 U.S.C. 5701(b) and 7332) Title 38, United States Code, allows us to ask for this information. We estimate that claimants and individuals appointed for purposes of
representation will each need an average of 5 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. A Valid OMB control number can be located on the OMB
Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
(Veteran, guardian, beneficiary, dependent, or next of kin)
2. NAME OF CLAIMANT
(No. and street or rural route, city or P.O., State an
d ZIP
3. ADDRESS OF CLAIMANT
Code)
4. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN
5. SERVICE NUMBERS
6. BRANCH OF SERVICE
AIR FORCE
(Specify
ARMY
NAVY
MARINE CORPS
COAST GUARD
)
OTHER
7A. NAME OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE
7B. INDIVIDUAL IS (check appropriate box)
INDIVIDUAL PROVIDING REPRESENTATION UNDER
SERVICE ORGANIZATION REPRESENTATIVE
ATTORNEY
AGENT
(Specify organization below)
SECTION 14.630
(*See required statement below. Signatures are
required in Items 7C and 7D)
*INDIVIDUALS PROVIDING REPRESENTATION UNDER SECTION 14.630
(Skip to Item 8, if the box for "Individual Providing Representation Under Section 14.630" was not checked in Item 7B)
The appointment of the individual named in Item 7A (the representative) authorizes the individual to represent the claimant named in Item 2 for a particular claim
pursuant to the provisions of 38 CFR 14.630. By our signatures below, we, the representative and the claimant, attest that no compensation will be charged or paid for
the individual named in Item 7A.
7C. SIGNATURE OF REPRESENTATIVE NAMED IN ITEM 7A
7D. SIGNATURE OF CLAIMANT NAMED IN ITEM 2
(No. and street or rural route, city or P.O., State, and ZIP code)
8. ADDRESS OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE
(Continued on Reverse)
VA FORM
SUPERSEDES VA FORM 21-22a, JUN 2009,
21-22a
AUG 2015
WHICH WILL NOT BE USED.
OMB Control No. 2900-0321
Respondent Burden: 5 Minutes
Expiration Date: 08/31/2018
1. VA FILE NO(S)
Include prefix)
(
APPOINTMENT OF INDIVIDUAL AS CLAIMANT'S REPRESENTATIVE
Note - If you would prefer to have a service organization assist you with your claim, you may use VA Form 21-22,
"Appointment of Veterans Service Organization As Claimant's Representative."
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA, published in the
Federal Register. Your obligation to respond is voluntary. However, failure to respond provide the requested information could impede the recognition of your representative and/or
identification of disclosable records. Except for information protected by 38 U.S.C. 7332, your representative is not prohibited from redisclosing records. The responses you submit are
considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to recognize the individuals appointed by claimants to act on their behalf in the preparation, presentation, and prosecution of claims for
VA benefits (38 U.S.C. 5902, 5903, and 5904) and for those individuals to accept appointment. We will also use the information to verify consent for disclosure of VA records to the appointed
representative (38 U.S.C. 5701(b) and 7332) Title 38, United States Code, allows us to ask for this information. We estimate that claimants and individuals appointed for purposes of
representation will each need an average of 5 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. A Valid OMB control number can be located on the OMB
Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
(Veteran, guardian, beneficiary, dependent, or next of kin)
2. NAME OF CLAIMANT
(No. and street or rural route, city or P.O., State an
d ZIP
3. ADDRESS OF CLAIMANT
Code)
4. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN
5. SERVICE NUMBERS
6. BRANCH OF SERVICE
AIR FORCE
(Specify
ARMY
NAVY
MARINE CORPS
COAST GUARD
)
OTHER
7A. NAME OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE
7B. INDIVIDUAL IS (check appropriate box)
INDIVIDUAL PROVIDING REPRESENTATION UNDER
SERVICE ORGANIZATION REPRESENTATIVE
ATTORNEY
AGENT
(Specify organization below)
SECTION 14.630
(*See required statement below. Signatures are
required in Items 7C and 7D)
*INDIVIDUALS PROVIDING REPRESENTATION UNDER SECTION 14.630
(Skip to Item 8, if the box for "Individual Providing Representation Under Section 14.630" was not checked in Item 7B)
The appointment of the individual named in Item 7A (the representative) authorizes the individual to represent the claimant named in Item 2 for a particular claim
pursuant to the provisions of 38 CFR 14.630. By our signatures below, we, the representative and the claimant, attest that no compensation will be charged or paid for
the individual named in Item 7A.
7C. SIGNATURE OF REPRESENTATIVE NAMED IN ITEM 7A
7D. SIGNATURE OF CLAIMANT NAMED IN ITEM 2
(No. and street or rural route, city or P.O., State, and ZIP code)
8. ADDRESS OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE
(Continued on Reverse)
VA FORM
SUPERSEDES VA FORM 21-22a, JUN 2009,
21-22a
AUG 2015
WHICH WILL NOT BE USED.
9. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38, U.S.C.
Unless I check the box below, I do not authorize VA to disclose to the individual named in Item 7A any records that may be in my file relating to treatment for drug
abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia.
I authorize the VA facility having custody of my VA claimant records to disclose to the individual named in Item 7A all treatment records relating to drug abuse,
alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia. Redisclosure of these records by my representative,
other than to VA or the Court of Appeals for Veterans Claims, is not authorized without my further written consent. This authorization will remain in effect until
the earlier of the following events: (1) I revoke this authorization by filing a written revocation with VA; or (2) I revoke the appointment of the individual named
in Item 7A, either by explicit revocation or the appointment of another representative.
10. LIMITATION OF CONSENT. My consent in Item 9 for the disclosure of records relating to treatment for drug abuse, alcoholism or alcohol abuse, infection
with the human immunodeficiency virus (HIV), or sickle cell anemia is limited as follows:
11. AUTHORIZATION FOR REPRESENTATIVE TO ACT ON CLAIMANT'S BEHALF TO CHANGE CLAIMANT'S ADDRESS
Unless I check the box below, I do not authorize the individual named in Item 7A to act on my behalf to change my address in my VA records.
I authorize the individual named in Item 7A to act on my behalf to change my address in my VA records. This authorization does not extend to any other individual
with out my further written consent. This authorization will remain in effect until the earlier of the following events: (1) I revoke this authorization by filing a
written revocation with VA; or (2) I revoke the appointment of the individual named in Item 7A, either by explicit revocation or the appointment
of another representative.
CONDITIONS OF APPOINTMENT
I, the claimant named in Item 2, hereby appoint the individual named in Item 7A as my representative to prepare,present, and prosecute my claims for any and all benefits
from the Department of Veterans Affairs (VA) based on the service of the veteran named in Item 4. If the individual named in Item 7A is an accredited agent or attorney,
the scope of representation provided before VA may be limited by the agent or attorney as indicated below in Item 15. If the individual indicated in Item 7A is providing
representation under 14.630, such representation is limited to a particular claim only. I authorize VA to release any and all of my records (other than as provided in Items
9 and 10) to that individual appointed as my representative, and if the individual in Item 7A is an accredited agent or attorney, this authorization includes the following
individually named administrative employees of my representative:
Signed and accepted subject to the foregoing conditions.
12. SIGNATURE OF CLAIMANT
13. DATE OF SIGNATURE
14. CLAIMANT'S RELATIONSHIP TO VETERAN
(If other than the veteran)
15. LIMITATIONS ON REPRESENTATION - AGENTS OR ATTORNEYS ONLY (Unless limited by an agent or attorney, this power of attorney revokes all
previously existing powers of attorney)
16. SIGNATURE OF REPRESENTATIVE
17. DATE OF SIGNATURE
FEES: Section 5904, Title 38, United States Code, contains provisions regarding fees that may be charged, allowed, or paid for services of agents or attorneys in
connection with a proceeding before the Department of Veterans Affairs with respect to benefits under laws administered by the Department.
VA Form 21-22a, AUG 2015

Download VA Form 21-22A Appointment of Individual as Claimant's Representative

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VA Form 21-22a Instructions

A representative has the authority to review information in the claimant's folder. If the representative holds Power of Attorney (or POA) for only one claim, they may review the information in the file pertaining only to that claim, unless the claimant specifically consents or authorizes the release of other information. The release of claimant's information will not occur without a completed 21-22a Form.

If VA Form 21-22a is not signed by the claimant, a representative is not eligible to review the claims file or receive any correspondence from VA including development letters, decision letters, or copies thereof.

A VA Regional Office (RO) may release a claimant's records to an attorney without a signed 21-22 Form in the following cases:

- when it received a request from the General Counsel Professional Group VII regarding representation of claimants in litigation before the U.S. Court of Appeals for Veterans Claims (CAVC);

- when it received a signed statement from the claimant authorizing VA to provide a copy of their folder to the attorney representing them.

How to Fill out VA Form 21-22a?

The form is fairly straightforward and shouldn't take more than 5 minutes to complete. Getting all the necessary signatures in the appropriate fields is essential. The claimant and the representative each sign on every page.

Most of the other fields are self-explanatory.

An important moment that can be easily overlooked is that there is a hidden field with no number on it on the second page in the section called "Conditions of Appointment." The small print should be readable. In the space that follows, a claimant can list all non-accredited team members who may call the VA regarding the status of their claim.

The form should be submitted as Intent to File a Claim box or as a Fully Developed Claim. It should also be included with any other correspondence, particularly when the third party is the individual signing the correspondence.

Step by step VA Form 21-22a Instructions are as follows:

  1. Box 1. Enter the VA file number of the claim case;
  2. Boxes 2-3. Personal information;
  3. Box 6. Branch of service of the veteran;
  4. Box 7A. Name of the party which will be acting as a representative;
  5. Box 7B. If the individual is a service organization representative, agent, or attorney, provide this information. For service organization representatives, the name of the organization should be given;
  6. Box 7D. Signature box. If a representative wishes to have access to confidential information, check the Authorization box in Question 9. Otherwise, skip it;
  7. Box 10 is to place any limitations on the information a claimant does not want to share.

For a representative:

  1. Box 7C. Sign the form;
  2. Box 8. Enter the full address;
  3. If the representative is an attorney or an agent, any limitations on the representation has to be listed in Box 15.
  4. Sign and date the form at the bottom.

Where to Send VA Form 21-22a?

Send the form to a local VA Office or present it in person.

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